Although gender nonconformity is not a mental disorder, GD is characterized by clinically significant mental anguish. Persons with GD often have impaired social and occupational functioning because of the marked difference between their expressed gender and their gender at birth. As transgender individuals, those with GD have a strong conviction that their feelings and actions are typical of the opposite gender, and they desire to live and be perceived as that gender. GD in children is marked by repeated verbalization of their desire to be the other gender as well as behaviours that indicate a strong preference to be/identity with the other gender, such as persistent cross-gender roles in make-believe play or a profound dislike for their sexual anatomy. In both children and adults, feelings of dysphoria must continue for at least six months for a diagnosis to be given.

With the development of successful surgical techniques and hormone replacement therapy, several thousand transsexual adults with persistent GD have undergone a permanent gender reassignment. Although both male and female transsexuals exist, the male-to-female operation is more common, because the genital reconstruction is more satisfactory. The male-to-female transsexual’s penis and testes are removed, and an artificial vagina is created; breasts may be implanted, although some breast development usually is promoted with the use of feminizing hormones. Female-to-male transsexuals may undergo mastectomy, hysterectomy, and hormone treatments to produce the male secondary sexual characteristics but may decide against a phalloplasty, as attempts to create an artificial penis have not been particularly satisfactory.

History

GD represents the evolution of a set of diagnoses that first appeared in American psychiatry in DSM-III in 1980. DSM-III included a diagnostic group called “Gender Identity Disorders,” which comprised “Transsexuality,” “Gender Identity Disorder of Childhood,” and “Transvestic Fetishism.” These diagnoses formalized medical and psychiatric thinking about gender-variant people that dated back to the 19th century, such as that as expressed by early sexologists Havelock Ellis, Karl Heinrich Ulrichs, and Magnus Hirschfeld. The DSM-III GD diagnostics were also shaped by a heightened mid-20th-century interest among a subset of psychiatrists and other medical and mental health professionals in gender variance. Their increased interest was primarily directed at the newly emerging medical and social category of transsexuality.

Since appearing in DSM-III, the GID entries have changed with each subsequent DSM revision. The most-significant revision was the DSM-IV (1994), which combined “Transsexualism” with “Gender Identity Disorder of Childhood” into one overarching diagnosis, “Gender Identity Disorder.” (“Transvestic Fetishism,” once listed among the gender disorders, has been reclassified as a sexual paraphilia.) DSM-5 further revised the diagnosis, which was renamed “gender dysphoria” and given its own chapter distinct from “Sexual Dysfunctions and Paraphilic Disorders.” This diagnostic label is more consistent with clinical sexology terminology and removes the connotation that people with gender nonconformity are “disordered” by only pathologizing the discontent experienced by these patients.

As outlined in DSM-5, a GD diagnosis is given when there is a strong and persistent alternate-gender identification and a sustained discomfort with one’s assigned sex or a sense of inappropriateness in the gender role of that sex. The diagnostic text lists specific examples of those criteria as they may manifest in children, adolescents, and adults. The criteria also disallow a diagnosis if an intersex condition is present. The alternate-gender identification or behaviours must also be accompanied by significant distress and impairment.

Controversy

Clinical GD diagnoses have been controversial since they first appeared. Beginning in the mid-1990s, the level of controversy and debate increased, partly because of the work of transgender, intersex, and gay and lesbian social movements but also because of critiques made within the medical and mental health professions both by individuals and by lesbian, gay, bisexual, and transsexual (LGBT) professional organizations.

Critics have argued that GD diagnoses continue a longstanding history of pathologizing oppressed peoples. Some argue that the diagnosis stigmatizes groups that are simply expressing variation, not pathology. Critics suggest that the diagnosis individualizes a broad cultural and social phenomenon and reinforces a binary mode of gender.

Although the revisions to DSM-5 have assuaged some criticism, it has been argued that the diagnosis of GD mistakenly categorizes a medical condition as a mental health disorder. These critics often point to recent research that may indicate a biological basis for transsexuality. Whereas some have lobbied for the elimination of the diagnosis, others have suggested that GD could be redesignated as a benign medical condition instead of a psychiatric disorder. However, because many transsexuals seek the services of medical and mental health professionals, some members of transsexual and transgender communities worry that removing or reforming the GD diagnosis could jeopardize the availability of sex reassignment surgeries and other procedures. There is also concern that, without the diagnosis, insurance reimbursements for such procedures could be threatened.

For gender-variant children, critics often argue that the diagnosis is too broad. Research on children diagnosed with GD suggests that they will most likely grow up to be gay or bisexual. Critics suggest that GD treatments for children focus too much on boys, that treatment may damage self-esteem, and that the distress that GD children exhibit is not inherent to their gender nonconformity but rather is a reaction to being stigmatized. Mental health professionals who support the diagnosis and treat GD children counter that their treatments help GD children to have better peer relations and thus bolstered self-esteem and that research indicates that GD children do exhibit forms of distress associated directly with their gender variance.